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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />--f—OF,-"OFFICE USE: VVV 1601 E. Hazeltorf`Ave`, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zg:J&R�� <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ <br /> ( (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereirildescribed. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. 4 <br /> "TRACTi <br /> JOB ADDRESS/LOCATION �,j.�9(� !� � CENSUS <br /> Owner's Name <br /> S501-L IV Phone .9n 092 <br /> E <br /> Address 1 f City- <br /> Contractor s <br /> ity-Contractors Name wf-L_ _DR191A A License # Phone <br />'TYPE-OFYWORK-(CheCIC)`i _ NEW'WELL``/DEEPEN'. %/ -RECONDITION_% / DESTRUCTI0iT_/[� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /4,7-- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /pp SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYiLINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC"WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial •3" Cable Tool Dia. of Well Excavation L2�A_4,1' _ <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casii <br /> Irrigation 11 Gravel Pack Depth of Grout •Seal - <br /> Cathodic Protection i� Rotary Type of Grout G - - T" <br /> Disposal Other Other Information - � x <br /> Geophysical Surface Seal Ins Called By E !'4 <br /> PUMP INSTALLATION.STALLATIDN: <br /> Contractor 44 V •+: < <br /> Type, of Pump \` . . - . ; `ti ! H,.P. s <br /> PUMP REPLACEMENT: / / State Work Done <br />'PUMP .REPAIR: / / State Work Done _ <br />"DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 1-t 1-4- L., <br /> II hereby agree to comply with all laws and regulations-of-,.;.rhe..San-Joaquin Local Health District <br /> I <br /> and the State of California pertaining to or regulating well construction. Within' FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we11 and notify them before putting the- well in use. The above <br />. information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TO GROUIINGIANDA I SPECTION. <br /> _ TITLE- <br /> (DRAW <br /> E <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SIvr�) <br /> .f FOR DEPART NT [75E ONLY <br /> i PHASE I [ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYAl- <br /> DATE r v INSPECTION BY DATE <br /> - i/77 - 2X <br />